Enhanced Surveillance for Pregnancy-Associated Mortality—Maryland, 1993–1998

COMPLETE AND ACCURATE IDENtification of all deaths associated with pregnancy is a critical first step in the prevention of such deaths. Only by having a clear understanding of the magnitude of pregnancy-associated mortality can comprehensive prevention strategies be formulated to prevent these unanticipated deaths among primarily young, healthy women. Death statistics compiled through the National Vital Statistics System by the National Center for Health Statistics, Centers for Disease Control and Prevention, are a major source of data on deaths occurring during pregnancy and in the postpartum period. Original death certificates from which state and national vital statistics are derived are filed in and maintained by individual states. Causes of death on death certificates are reported by attending physicians or, under certain circumstances such as death from external trauma or unexplained death, by medical examiners or coroners. The National Center for Health Statistics is required to use the World Health Organization (WHO) definition of a maternal death for preparation and presentation of mortality data. According to the WHO definition, a maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.” This definition includes deaths assigned to the cause “complication of pregnancy, childbirth, and the puerperium” (International Classification of Diseases, Ninth Revision [ICD-9] codes 630-676). Death records are an important source of data on pregnancy mortality because they are routinely collected by the states and are comparable over time and across the nation. However, there are several limitations to using these data to identify all deaths associated with pregnancy. First, the cause-of-death information provided on these records is sometimes not accurate. Previous studies have shown that physicians completing death records following a maternal death fail to report that the woman was pregnant or had a recent pregnancy in 50% or more of these cases, resulting in the misclassification of the underlying cause of death. Since these deaths cannot be identified as maternal deaths through routine surveillance